Gout Flashcards
Risk of gout is defined as what level of uric acid in women?
> 7 mg/dL
Risk of gout is defined as what level of uric acid in men?
> 6 mg/dL
What accounts for 90% of the reason/pathophys for gout in pt’s?
Underexcretion of uric acid:
Relative decrease in renal excretion of uric acid for an unknown reason=Primary Idiopathic hyperuricemia
List high and moderately high purine rich foods (5-100 mg/3.5 oz serving)
- Meats: beef, seafood
2. Fast-growing vegetables: spinach, asparagus
List very high purine rich foods (1,000 mg/3.5 oz serving)
Anchovies
Organ meats
Sardines
How much purines does the average daily US diet contain?
600-1,000 mg
List the drugs that can induce hyperuricemia
- Cytotoxic drugs
- Cyclosporine
- Diuretics
- Ethanol
- Ethambutol
- Levodopa
- Nicotinic acid
- Pyrazinamide
How long does an acute gout attack last for?
3-10 days
List the two components of chronic gout
- Rheumatoid-like
2. Tophaceous Gout: Monosodium urate in soft tissues and joints
What is the definitive diagnosis for gout?
Tapping joint and microscopic exam for uric acid crystals
List the anti-inflammatory of choice in the treatment of gout
DMARDs
List the treatment for acute gout
- NSAIDs
2. Corticosteroids
List the treatment for chronic gout
- Colchicine
- Probenicid (uricosuric)
- Allopurinol, febuxostat: xanthine oxidase inhibitors
Colchicine MOA
- Decreases macrophage migration and phagocytosis
2. Inhibits leukotriene B4=Decreases inflammation
When does Colchicine need to be administered?
Within 36 hrs. of acute attack onset
Colchicine dosing
1.2 mg followed by 0.6 mg in 1 hr
Colchicine ADE’s
Dose-dependent GI ADE’s: N/V/D
When is dose adjustment recommended in Colchicine?
When used with:
- Selected CYP3A4
- P-glycoprotein inhibitors
List the oral form of corticosteroids used in gout
Oral Methylprednisolone dose pack
List the IM form of corticosteroids used in gout
IM Triamcinolone: to be followed by oral prednisone or prednisolone
When would you consider using intra-articular (TAC-Kenalog) administration?
Only 1-2 joints are involved
Used in combo with NSAIDs, Colchicine or oral corticosteroids
What type of medications are needed during the initiation of rate-lowering therapy? for how long?
Anti-inflammatories:
@ least 6 months OR
3-6 months after achieving target serum uric acid
What are the anti-inflammatory options during the initiation of rate-lowering therapy
- Colchicine 0.6 mg 1-2x daily
- Low dose NSAIDs w/ PPI
- Prednisone <10 mg/day
What is efficacious for the prophylaxis of recurrent gout attacks in BOTH underexcreters and overprices of uric acid?
Xanthine Oxidase Inhibitors (XOI):
- Allopurinol
- Febuxostat
What are the indications for initiating Allopurinol or Febuxostat (XOI’s)
- 2 or more gout attack per year
- 1 or more tophus
- CKD (stage II or worse)
- Hx urolithiasis
What ADE do you want to educate your patients about when using Allopurinol?
Acute Hypersensitivity Syndrome (AHS)
What high risk populations (for AHS) do you consider genetic testing in?
- Koreans w/ CKD
2. Han Chinese and Thai irrespective of renal function
Allopurinol MOA
IRREVERSIBLY inhibits xanthine oxidase=lowers uric acid production
Febuxostat MOA
REVERSIBLE inhibitor of xanthine oxidase
Febuxostat is CI with the use of what?
Azathioprine
Febuxostat ADE
Liver enzyme elevation
Febuxostat toxicities
- Liver function test
- Renal function
*BUT NO dose adjustments in pt’s with mild/mod renal (CrCL 30-89) or hepatic impairment
What is the effect of Probenecid?
Increase uric acid excretion
What is the benefits and considerations in using XOI + Fenofibrate or losartan?
- Augments uric acid excretion
2. Beneficial in pt’s with other disorders
When would you consider using for refractory gout to conventional therapy?
Pegloticase= Biologic
What must you use with Lesinurad? Why?
Combo w/ XOI’s d/t increased risk of acute renal failure with mono therapy
List the Interleukin-1 Inhibitors and indications for them
Anakinra
Rilonacept
Canakinumab
ACUTE gout
Refractory to traditional therapy
CI to current tx’s
